Provider Demographics
NPI:1588349948
Name:THOMPSON, MARY AGNES
Entity type:Individual
Prefix:
First Name:MARY AGNES
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 SWAN RIDGE CIR N
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38122-4600
Mailing Address - Country:US
Mailing Address - Phone:901-907-4426
Mailing Address - Fax:
Practice Address - Street 1:3801 SWAN RIDGE CIR N
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38122-4600
Practice Address - Country:US
Practice Address - Phone:901-907-4426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health